Health Assessment: Nurse's Role in Health Assessment
Nursing Diagnoses
Analysis of subjective and objective data to make a professional nursing judgment
Implementation
Carrying out the plan of care
Nursing Diagnosis
Collection of Subjective and Objective Data
Planning
Developing a plan of nursing care and outcome criteria
perception of pain
During an interview, the nurse collects both subjective and objective data from an adult client. Subjective data would include the client's
allow the client to ventilate his or her feelings
The nurse is beginning a health history interview with an adult client who expresses anger at the nurse. The best approach for dealing with an angry client is for the nurse to
encourage the client to quit smoking
The nurse is interviewing a client in the clinic for the first time. When the client tells the nurse that he smokes "about two packs of cigarettes a day," the nurse should
'how do you manage your stress"
While interviewing an adult client about the client's stress levels and coping responses, an appropriate question by the nurse is
prone position
client lies on abdomen with head turned to side; may be used to asses back and mobility of hip joint
palpation
during a comprehensive assessment, the primary technique by the nurse throughout the examination is
dorsal surface of the hand
while examining a client, the nurse plans to palpate temperature of the skin by using the
maintain eye contact while asking the questions from the form
while interviewing a client for the first time, the nurse is using a standardized nursing history form. the nurse should
Evaluation
Assessing whether outcome criteria have been met and revising the plan as necessary.
using closed-ended questions
During an interview with an adult client, the nurse can keep the interview from going off course by
Objective data
Findings directly observed or indirectly observed through measurements (e.g., body temperature)
Collaborative problem
Physiologic complications that nurses monitor to detect their onset or changes in status
sitting position
Position used during much of the physical examination including examination of the head, neck, lungs, chest, back, breast, axilla, heart, vital signs, and upper extremities
Subjective data
Sensations or symptoms that can be verified only by the client (e.g pain)
provide structure and set limits with the client.
The nurse is planning to interview a client who has demonstrated manipulative behaviors during past clinic visits. During the interview process, the nurse should plan to
expressing interest in a neutral manner
The nurse is planning to interview a client who is being treated for depression. When the nurse enters the examination room, the client is sitting on the table with shoulders slumped. The nurse should plan to approach this client by
explain the role and purpose of the nurse
The nurse is preparing to interview an adult client for the first time. The nurse observes that the client appears very anxious. The nurse should
wash both hands with soap and water
Wash beginning a physical assessment of a client, the nurse should first
Continuous
although the assessment phase of the nursing process precedes the other phases, the assessment phases is
supine position
back-lying position used for examination of the abdomen (with one small pillow under the head and another under knees); this position also allows easy access for palpation of peripheral pulses
Nursing Assessment
clinical judgement about individual, family, or community responses to actual or potential health problems and life processes.
identify risk factors to the client and his or her significant others
during a client interview, the nurse asks questions about the clients past health history. the primary purpose of asking about past health problems is to.
1 1/2 inch diaphragm
during a comprehensive assessment of an adult client, the nurse best hear high-pitched sounds by using a stethoscope with a
Hyperresonance
during a comprehensive assessment of lungs of an adult client with a diagnosis of emphysema, the nurse anticipates that during percussion the client will exhibit
working
during an interview between a nurse and a client, the nurse and the client collaborate to identify problems and goals. this occurs during the phase of the interview termed
rephrasing the client's statements
during an interview with an adult client fro the first time, the nurse can clarify the client's statements by
knowledge of his or her own thoughts and feelings about these issues
for a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness or sexuality, the nurse should have
Diaphragm
larger end of stethoscope used to detect breath sounds, normal heart sounds, and bowel sounds
fingerpads
part of examiner's hand used to feel fine discriminations: pulses, texture, size, consistency, shape and crepitus
dorsal surface of hand
part of examiner's hand used to feel for temperature
ulnar surface or palm of hand
part of examiner's hand used to feel fro vibration, thrills, or premitus
standing position
position used to examine male genitalia and to asses gait, posture, and balance
Referral problem
problem that requires the attention or assistance of other health care professionals.
Sims position
side-lying position used during the rectal examination
rapid advances in biomedical knowledge and technology.
the depth and scope of nursing assessment has expanded significantly over the past several decades primarily because of
indirect percussion
the most commonly used method of percussion is
indicate acceptance of the client's cultural differences
the nurse has interviewed a Hispanic client with limited English skills for the first time. The nurse observes that the client is reluctant to reveal personal information and believes in a hot-cold syndrome of disease causation. the nurse should.
explain each procedure being performed and the reason for the procedure
to alleviate a client's anxiety during a comprehensive assessment, the nurse should
review the client's health care record
to prepare for the assessment of a client visiting a neighborhood health care clinic, the nurse should first
comprehensive
when a client first enters the hospital for an elective surgical procedure, the nurse should perform an assessment termed
avoids excessive eye contact with the client
During a client interview, the nurse uses nonverbal expressions appropriately when the nurse
Formulation of nursing diagnoses
The result of a nursing assessment is the
asses the client's hearing acuity
the nurse is interviewing a 78-year-old client for the first time. The nurse should first
use very basic lay terminology
the nurse is interviewing a client in the clinic for the first time. the client appears to have a very limited vocabulary. the nurse should plan to
avoid premature judgment about the client
the nurse is preparing to meet a client in the clinic for the first time. after reviewing the client's record, the nurse should
blunt percussion
when the nurse places one hand flat on the body surface and uses the first of the other hand to strike back of the hand flat on the body surface, the nurse is using
review the ChoosemyPlate information with the client
while interviewing an adult client about her nutrition habits, the nurse should
check for the presence of defining characteristics
To arrive at a nursing diagnosis or a collaborative problem, the nurse goes through the steps of analysis of data. After proposing possible nursing diagnoses, the nurse should next
bone
while percussing an adult client during physical examination, the nurse can expect to hear flatness over the client's
Physiologic status
A medical examination differs from a comprehensive nursing examination in that the medical examination focuses primarily on the client's
lithotomy position
Back-lying position with hips at edge of examining table and feet supported in stirrups; used for examination of female genitalia, reproductive tract, and rectum
arrive at conclusions about the client's health
Before beginning a comprehensive health assessment of an adult client, the nurse should explain to the client that the propose of the assessment is to
Bell of stethoscope
Smaller end of stethoscope used to detect low-pitched sounds (abnormal heart sounds and bruits)
deep palpation
an adult client visits a clinic and tells the nurse that she suspects she has a urinary tract infection. to detect tenderness over the client's kidneys, the nurse should instruct the client that he or she will be performing
ongoing or partial assessment
an assessment of a client who already has a complete recorded database in the system and returns to the health care agency with a specific health concern is referred to as a(n)
deep palpation
during palpation of a client's organs, the nurse palpates the spleen by applying pressure between 2.5 and 5 cm. the nurse is performing
provide the client with information as questions arise
during the interview of an adult client, the nurse should
percussion
while performing a physical examination on an adult client, the nurse can detect the density of an underlying structure by using
use minimal position changes
while performing a physical examination on an older adult, the nurse should plan to